Before blaming SARS-CoV-2 vaccination for aortic dissection, alternative causes need to be ruled out

Letter to the Editor

We read with interest the article by Takahashi et al. about an autopsy case of a > 90 years old male who was found dead in his kitchen about two weeks after the third dose of the BNT162b2 (Biontech Pfizer) anti-SARS-CoV-2 vaccine [1]. Autopsy revealed that the patient had pericarditis and consecutive aortic dissection type-A [1]. Pericarditis was interpreted as causally related to the vaccination and to aortic dissection [1]. The study is promising but raises concerns that should be discussed.

The main limitation of the study is that the patient was not tested for SARS-CoV-2 by PCR. Acute SARS-CoV-2 infections have been repeatedly reported to be complicated by spontaneous dissections of various arteries, including the aorta. In a 67 years old male with a history of arterial hypertension, hyperlipidemia, and aortic valve replacement, COVID-19 was complicated by aortic dissection type-A [2]. A 43 years old male with Fabry disease experienced spontaneous aortic dissection four months after a SARS-CoV-2 infection [3]. There is further evidence for a causal relationship between SARS-CoV-2 infection and aortic dissection from other case reports [4]. As long as an acute SARS-CoV-2 infection has not been ruled out, a causal relation between vaccination and pericarditis cannot be established. A further argument against vaccination as the cause of pericarditis is that the patient had two vaccine doses before without obvious side effects.

A second limitation of the report is that the pathophysiological explanation that dissection resulted from pericarditis remains unproven. A strong argument against the adventitial hypothesis is that autopsy found a 2.5 cm intimal tear at 4 cm above the aortic annulus [1], suggesting that dissection occurred rather from the interior than from the exterior side of the aorta. A strong shortcoming in this regard is that no information about the histological appearance of the endothel was provided. We should know if there were any indications also for inflammation of the endothel and not only the muscularis and the adventitia. A feature of arteriopathy in SARS-CoV-2 can be endothelialitis.

Another limitation is that spontaneous rupture without any relation to the vaccination was not considered. Given the fact that the patient was > 90 years, and that the prevalence of aortic dissection increases with age [5], it cannot be ruled out that the case represents rather a case of spontaneous dissection than aortic dissection due to the vaccination.

Furthermore, there is no mentioning of the current medication. We should be informed not only about the medication the patient received when he consulted a doctor in a private office but also about the medication he was regularly taking at home.

Missing is the information whether dissection also involved the carotid and vertebral arteries.

Overall, the interesting report has limitations that call the results and their interpretation into question. Clarifying these weaknesses would strengthen the conclusions and could improve the study. Before blaming SARS-CoV-2 vaccinations for pericarditis and aortic dissection, alternative causes should be considered and appropriately ruled out.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.